Totally extra-peritoneal repair for acute incarcerated femoral hernia with intestinal obstruction

The Utility of Minimally Invasive Surgery in the Emergency Management of Femoral Hernias: A Systematic Review

Background: Femoral hernias are a relatively rare type of hernia but have a high complication rate, with a high proportion either presenting as an emergency or requiring emergency management. Minimal access surgery has been shown to be safe, with good results, in an elective setting, but there is little published evidence of its utility in an emergency. Methods: A systematic review was conducted searching PubMed, OVID, Embase, and Cochrane reviews for ((Femoral hernia) AND (laparoscop* OR minimal access OR robotic)) AND (strangulat* OR obstruct* OR incarcerat*). Results: 286 manuscripts were identified of which 33 were relevant. 24 were individual case reports, 3 case series, 4 cohort studies or case control series, and 2 high level reviews of National registers. Conclusion: Minimal access surgery can avoid an unnecessary laparotomy for the assessment of hernial contents, especially via a TAPP approach. Minimal access repair of femoral hernias as an emergency is feasible and can be done safely with results similar to open surgery but good quality evidence is lacking.

Open preperitoneal vs. open anterior repair for the treatment of emergency femoral hernia: a bicentric retrospective study

PURPOSE

The aim of this study is to compare the postoperative results, in terms of complications and recurrence, between the anterior and open preperitoneal approaches in emergency femoral hernia.

METHODS

This bi-centric retrospective cohort study included patients who underwent emergency femoral hernia repair between January 2010 and December 2018. Postoperative complications and recurrence were analyzed comparing anterior and open preperitoneal approaches. The predictors of complications, mortality and recurrence were investigated using multivariate logistic regression.

RESULTS

A total of 204 patients met the inclusion criteria. Open anterior approach was performed in 128 (62.7%) patients and open preperitoneal was performed in 76 (37.3%). Open preperitoneal approach was associated with lower rates of recurrence (P = 0.033) and associated midline laparotomies (P = 0.006). Multivariable analysis identified patients with chronic nephropathy (OR, 3.801; 95%CI, 1.034-13.974; P = 0.044), preoperative bowel obstruction (OR, 2.376; 95%CI, 1.118-5.047; P = 0.024) and required midline laparotomy (OR, 12.467; 95%CI, 11.392-102.372; P = 0.030) as risk factors for complications and ASA ≥ III (OR, 7.820; 95%CI, 1.279-47.804; P = 0.026), COPD (OR, 5.064; 95%CI, 1.188-21.585; P = 0.028), necrotic contents (OR, 36.968; 95%CI, 4.640-294.543; P = 0.001), and required midline laparotomy (OR, 11.047; 95%CI, 1.943-62.809; P = 0.007). as risk factors for 90-day mortality. Male gender (OR, 4.718; 95%CI, 1.668-13.347; P = 0.003) and anterior approach (OR, 5.292; 95%CI, 1.114-25.149; P = 0.036) were risk factors for recurrence.

CONCLUSION

Open preperitoneal approach may be superior to anterior approach in the emergency setting because it can avoid the morbidity of associated midline laparotomies, with a lower long-term recurrence rate.

Comparison of mesh repair and suture repair for the treatment of incarcerated femoral hernia: a retrospective, single-center study

BACKGROUND

Femoral hernias often present with incarceration or strangulation that requires emergency surgery. However, recommendations vary regarding optimal approaches for incarcerated femoral hernia. The aim of this study is to compare clinical efficacy between mesh repair and suture repair for the treatment of incarcerated femoral hernia.

METHODS

Retrospective, single-center analysis of the clinical data from 48 patients with incarcerated femoral hernia, including 16 patients who underwent mesh repair (mesh repair group) and 32 patients who underwent traditional suture repair (suture repair group).

RESULTS

The mean age, body mass index, incarceration duration, hernia sac size, operation duration, and the rates of postoperative incision infection, recurrence, chronic pain, and mortality were not significantly different between the suture repair and mesh repair groups (P > 0.05 for all). In contrast, the female/male ratio; the rates of bowel obstruction, coexisting diseases, and nighttime operation; and the American Society of Anesthesiologists grade were higher and the rate of prophylactic antibiotic use and the mean cost of hospitalization were lower in the suture repair group than in the mesh repair group (P < 0.05 for all).

CONCLUSION

The surgical approach should be chosen based on the patient's condition. Mesh repair for the emergency treatment of incarcerated femoral hernia is safe and effective, whereas suture repair is suitable for elderly patients, those with more coexisting diseases, and those with limited life expectancy.

Outcomes of laparoscopic repair in complicated groin hernia: A single institutional based cohort study in Nepal

Introduction

Laparoscopic hernia repairs have comparable recurrence rate with less persisting pain and numbness and quicker return to usual activities as compared to open mesh repair. The excellent outcomes of minimally invasive surgery encourage us to extend the laparoscopic technique to complicated groin hernia.

Method

A total of 22 patients with complicated groin hernia who presented to our institute from September 2017 to September 2018 were included in this prospective cohort study. Inclusion criteria were patients with age greater than 18 years and clinically diagnosed as complicated groin hernia. Patients with peritonitis, those with previous abdominal surgery and unfit for general anesthesia were excluded from our study.

Results

The most common age group was 51–60 (31.8%) years.17 cases were repaired with totally laparoscopic approach (12 TEP, 5 TAPP). Laparoscopic repair with additional procedure was needed in 3 cases and 2 cases were converted to open for completion of the procedure. The mean operating time was 154.8 ± 51.6 (range: 90 to 230) minutes. The average length of hospital stay was 3.8 ± 3 (range: 1 to 12) days. Bleeding from the inferior epigastric and testicular vessels were the major intra-operative complication (11.8%). Seroma and surgical site infection were seen in 2 (11.8%) patients.

Conclusion

Laparoscopic approach in cases of complicated groin hernia can achieve desirable patient outcomes without major complications, provided good patient selection and expertise. The evidence for laparoscopic repair as the choice of procedure in complicated groin hernia can be established from further comparative studies.

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Laparoscopic repair in complicated hernia has been attempted more frequently due to availability of expertise and detailed knowledge of anatomy.

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Successful reduction of hernia contents in laparoscopic repair is possible with minimal complications.

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Complications in laparoscopic repair in complicated hernia (intraoperative/postoperative) are comparable to that of laparoscopic repair of uncomplicated hernia or open repair of complicated hernia.

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Mesh can be used in laparoscopic repair of uncomplicated hernia.

Laparoscopic approach as a safe and effective option for incarcerated femoral hernias

INTRODUCTION

The laparoscopic approach for elective femoral herniorrhaphy is well established. However, femoral hernias often present as incarcerations and require emergency repair surgery, mainly using the open approach. This study aimed to retrospectively analyze the efficacy of the laparoscopic approach for incarcerated femoral hernias.

METHODS

Data of patients who underwent emergency surgery for incarcerated femoral hernia between April 2016 and August 2021 were retrospectively analyzed. Laparoscopy was performed whenever possible; however, conversion to an open approach remained a fallback option for when laparoscopic repair was not possible. In laparoscopic repair, incarcerated femoral hernias reduced using traction, water pressure, and preperitoneal methods. Data of patients who underwent open repair and laparoscopy were then compared.

RESULTS

During the observation period, 20 patients underwent emergency surgery for incarcerated femoral hernia. Eleven patients subsequently underwent repair using a laparoscopic approach, and eight underwent repair using an open approach. Only one patient underwent intestinal resection without hernia repair due to perforated bowel. Operative time for laparoscopic repair was longer. Mesh repair was performed in 18 patients. Four patients each in the laparoscopic repair and open group required intestinal resection.

CONCLUSION

Incarcerated femoral hernias can be safely repaired using the laparoscopic approach.

Incarcerated femoral hernia treated with elective totally extraperitoneal repair: a case report

Incarcerated groin hernia is a common surgical emergency. However, reports of incarcerated femoral hernia treated with elective totally extraperitoneal repair are extremely rare. A 62-year-old woman visited our hospital with lower abdominal pain and bulging from a right groin lesion. The patient was diagnosed as having right incarcerated femoral hernia containing greater omentum by computed tomography. As there were no clear findings of intestinal obstruction and peritonitis, elective surgery was performed. Intraoperatively, the hernia sac had herniated into the right femoral canal. We could release the hernia sac using laparoscopic forceps. After reduction of the hernia sac, polypropylene mesh was placed in the preperitoneal space and fixed to Cooper's ligament. The patient's postoperative course was uneventful, and she was discharged 3 days after surgery. We consider elective totally extraperitoneal repair for incarcerated femoral hernia to be an effective procedure for selected patients who have been diagnosed accurately.

Minimising recurrence after primary femoral hernia repair; is mesh mandatory?

PURPOSE

The recent international hernia guidelines advocate laparoscopic pre-peritoneal mesh repair for primary femoral hernias. However, no randomised trial has demonstrated a lower recurrence rate compared to suture repair. This study aimed to determine the 5-year recurrence rate following femoral hernia repair, in elective and emergency settings, according to surgical approach (open or laparoscopic) and method (suture, suture + mesh, or mesh alone).

METHODS

Consecutive patients undergoing primary femoral hernia repairs within a single health board, between 2007 and 2013, were identified from a prospective audit. Patients who had died or were uncontactable during the period of follow-up were excluded. Recurrence was defined as the clinical suspicion of an ipsilateral groin hernia at outpatient review or patient reported ipsilateral groin swelling.

RESULTS

A total of 297 patients underwent primary femoral hernia repairs in the time period. Of the 138 cases with complete follow-up, 25 patients experienced recurrence at 5 years (18%), with 60% of recurrences evident within the first post-operative year. The median follow-up of the remaining 113 patients was 93 months (range 63-127). No difference could be detected in recurrence rates (P = 0.372, P = 0.353), or time to recurrence (P = 0.421, P = 0.295), according to repair type (suture only, suture and mesh, or mesh only) or surgical approach (high open, low open and laparoscopic pre-peritoneal), respectively.

CONCLUSIONS

Use of different surgical approaches and types of repair for primary presentations of femoral hernia did not affect the recurrence rate or time to recurrence. Use of a pre-peritoneal mesh did not alter the recurrence rate or recurrence free survival, in either elective or emergency settings, compared to simple suture repair. Recurrence following primary femoral hernia repair tends to occur within the first post-operative year, suggesting that technical factors may be as important as suture or mesh failure.

Is the Laparoscopic Approach Feasible for Reduction and Herniorrhaphy in Cases of Acutely Incarcerated/Strangulated Groin and Obturator Hernia?: 17-Year Experience from Open to Laparoscopic Approach

Purpose: Management strategies for acutely incarcerated/strangulated groin and obturator hernias may differ from institution to institution, although, conventionally, the open approach has been used. Recently, laparoscopic transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair have become commonly used operative procedures for the repair of groin hernias. It is unclear whether laparoscopic reduction and herniorrhaphy can be successfully accomplished in all cases. This study was aimed at assessing the effectiveness of laparoscopic treatment. Methods: We conducted a prospective clinical trial of the laparoscopic approach from December 2011 and comparatively analyzed the surgical outcomes between the open and laparoscopic approaches for incarcerated/strangulated hernias seen from December 2000 to March 2017. Results: The open approach for repair was used in 54 patients (50.9%) and the laparoscopic approach in 52 patients (49.1%). There was 1 case in which from the laparoscopic approach to laparotomy (1.9%) was required. The operation time treated by the laparoscopic approach was significantly longer than the open approach (126.4 minutes versus 104.6 minutes; P = .0079); however, the incidence of postoperative complications and the postoperative length of hospitalization were also less in the former group than in the latter group (3.9% versus 18.5%; P = .0172 and 5.6 days versus 14.7 days; P = .0096). Second-stage TAPP herniorrhaphy was performed in 7 patients (15.2%) after bowel resection or closure of bowel perforation, and first-stage TEP herniorrhaphy was performed in 1 patient after bowel resection. There was no case of mesh infection in the group treated by the laparoscopic approach, and there was 1 case of mesh infection in the group treated by the open approach. The mortality rate was 0% in the group treated by the laparoscopic approach. Conclusions: Laparoscopic reduction and herniorrhaphy for acutely incarcerated/strangulated groin and obturator hernias is effective, safe, and feasible.

Minimally invasive approach to incarcerated or strangulated groin hernias: A 2018 EAST Master Class Video Presentation

Groin hernia repair is one of the most common general surgical procedures performed worldwide. Although only a small percentage will become incarcerated or strangulated, this is an indication for repair. Minimally invasive surgery is becoming the standard of care for most procedures, and we believe this to be a safe and feasible approach for incarcerated or strangulated groin hernias. We present a description of our recommended approach with technical details and accompanying video clips to highlight these techniques.